Joey Wahler (Host): It's an innovative treatment addressing a common male condition. So we're discussing aquablation therapy for enlarged prostate with a renowned urologist who's leading the way in use of this procedure in Central New York. Our guest, Dr. Andres Madissoo, a Urologist for Crouse Health. This is Crouse HealthCast, where we bring you the latest in health related news and information straight from the experts at Crouse Health.

Thanks for joining us. I'm Joey Wahler. Hi there, Doctor. Welcome.

Andres Madissoo, M.D.: Hey, thank you for having me.

Host: Great to have you with us. So first, what in a nutshell is aquablation therapy and how does it help in treating an enlarged prostate?

Andres Madissoo, M.D.: So, aquablation is an innovative advanced therapy. It's minimally invasive for treatment of benign prostatic hyperplasia otherwise known as BPH. It's different than many other therapies out there. Typically, males come in and very common, in fact, it's one of the most common reasons why males will seek urologic care.

Somewhere about half of men above 50 years of age will experience some BPH symptomatology. Those symptoms could include things like diminished urinary stream, voiding more frequently than normal, having urgency, have to go to the bathroom almost immediately when they get the urge. Often times getting up more than once or twice a night and in addition to sensing as though they're not emptying their bladder to completion.

Often times treatment will start with medications. And then move on to other therapies, and aquablation is one of the most innovative new therapies available. Very much different than the current therapies, otherwise, surgically, that we utilize.

Host: And so speaking of which, leads me beautifully into my next question. How does this therapy differ from those traditional treatments for enlarged prostate?

Andres Madissoo, M.D.: So, most of the therapies out there currently, utilize some form of heat in order to eliminate some of the tissue. One of the oldest therapies out there, surgically, has been the transurethral resection of prostate. And that's been around for well over 50 years. That's what most guys would refer to as a rotor rooter, and that would utilize a hot, wire in order to remove prostate tissue sequentially. That had some problems. It was one of the early therapies when I first started in practice about 25 years ago, that was really the only therapy that was utilized to open up the prostate channel widely.

And that was limited, in time. You could only resect tissue for about an hour based on the fluids that we're using. And then you had to stop, which would obviously limit how much tissue we could remove and what size prostates we could treat. The next therapies out there included things like laser therapies or plasma therapies where, again, you're utilizing heat in order to remove tissue.

And the problem with heat is that it does cause some irritative symptoms afterward, and also increases the risk of potential sexual side effects as the nerves that help with erections and urinary control to some degree, run alongside the prostate and nerves don't like the heat and being cooked in a sense.

And, so that does lead to increased risk of potential side effects and risks after these procedures. Aquablation, on the other hand, utilizes a room temperature fluid in order to resect the tissue and it uses saline, which is basically just IV fluid and removes the tissue, sequentially and, or robotically, and then we go in at the end of the procedure and cauterize any small vessels that may be bleeding.

So we eliminate the heat issue with the nerves and thereby reducing the risk of potential sexual side effects after the procedure.

Host: And so you touched on it a bit, but in layman's terms, what is it that you're looking to accomplish that makes the prostate more healthy?

Andres Madissoo, M.D.: So every male, as we enter into puberty, your prostate starts growing and it grows your entire life. The problem with that is that it's at the the base of the bladder. So when males have to urinate, the urine is stored in the bladder, urinate through the prostate, into the urethra, and then out of the body.

As the prostate is wrapped around the urethra at the base of the bladder, the urine has to flow through the prostate to get out, and as it enlarges, it tightens down on the prostate channel and subsequently the urethra, and as a result, males start developing those obstructive symptoms. Not every male with a enlarged prostate needs treatment, but if the symptoms become problematic; that's where therapies such as this are utilized.

Host: Gotcha. So mentioned at the top that you've been a leader in applying this procedure. What inspired you in the first place to pursue this new treatment method?

Andres Madissoo, M.D.: So having been in practice for about 25 years, I've seen a lot of variations of treatments that have come through. There's not been a whole lot of change as far as eliminating the heat portion. I've always been somewhat intrigued about aquablation. It first came around approximately 2013.

The first variation of the machinery, was called AquaBeam. And, since that time, there's been about 70,000 aquablation type procedures performed. Recently the company, Procept BioRobotics, who makes the aquablation therapy machine; they have come up with a new variation, it's called HYDROS.

This was first introduced, and first utilized in the world in September of 2024. And the procedure was performed in Hackensack, New Jersey. And, subsequently, at our large meeting is when I first, called the American Urologic Association meeting that they have every year; I was introduced to the machinery and when the new variation of the machinery came to pass, I was much more interested as it has many factors.

It's an integrated tower that improves the workflow for us. It has a simultaneous view of both the prostate channel inside the prostate, as well as the prostate on ultrasound imaging, so we see two different views of the prostate while we're treating it. It has a, integrated cystoscope, or the scope that we use to look into the bladder with a wider field of view, and it's a digital, disposable scope, so we get a much better picture of the area where we're working.

And it also utilizes AI, which is a big catchword these days, uses artificial intelligence to help with recognizing the soft tissues and coming up with a treatment plan in order to open up the prostate channel. So, really been interested in utilizing it since that time.

Crouse Hospital has been on the forefront of always getting equipment and staying in the forefront of technology. The first aquablation procedure in the world, as I stated, was performed in September of this past year. Crouse had bought the machinery in November of last year, and it was actually the second unit purchased in New York State.

So this is very much on the forefront of urology now. And, it's much improved than it was when it first started out with better visualization and less bleeding with the new technology used.

Host: And so, Doctor, who would be a good candidate for this treatment and how do you determine that? Is anyone not a good candidate?

Andres Madissoo, M.D.: Yeah, the workup that we perform when we first see a patient is first of all, we do a good physical examination, go over their history, see the symptoms that they're having. We typically will check a PSA to be sure we're not dealing with any risk of prostate cancer. After that, the usual workup would include performing what's called a transrectal ultrasound, which is essentially a glorified rectal exam.

Instead of the finger, we place a transrectal ultrasound probe into the rectum and we can get an exact measurement of the prostate. In addition, we'll take a small fiber optic scope along with some lidocaine numbing jelly in the urethra and actually take a look into the urethra, assess the prostate shape and configuration.

And from there, as long as they don't have any other reason for their symptoms; then, they're really a good candidate. There's almost any size prostate and any shape prostate, that we can treat with aquablation. There's several procedures out there that are minimally invasive, but many of those patients that we investigate will not be good candidates for the minimally invasive options such as UroLift and potentially Rezum based on the configuration of the prostate or certain sizes.

Host: And so during the procedure itself, what can patients expect?

Andres Madissoo, M.D.: So once we elect to proceed with the procedure itself, patient will get cleared by their primary care physician. The procedure itself, they'll come into the hospital, Crouse. And anesthesia will put them under full anesthesia, takes about 45 minutes for the entire procedure from start to finish.

The procedure itself, we place them in what's called a lithotomy position, essentially like having a baby, once they're knocked out. Then we put a transrectal ultrasound probe in the rectum, that's how we actually visualize the prostate during treatment. Then we place a scope into the urethra.

That's where the robotic aqua jet is deployed. And we're watching both visually with the scope, as well as by ultrasound while we're performing the procedure. Once we do the mapping, which is the ultrasound portion of the procedure, then the robotic system resects the tissue. It takes two passes, typically through the prostate.

Each pass is about four minutes. So the removal of tissue period is approximately 10 minutes total with the two passes. Then we'll take the scope out of the urethra. We place another type of scope into the urethra, cauterize any small vessels that may be bleeding, and then we do place a catheter at the end of the procedure.

So the whole procedure from start to finish is about 45 minutes. After that, the patient is woken up. They will wake up with a catheter, they will go home with a catheter. Some patients will stay overnight. And others will, if the urine remains clear immediately, oftentimes we can go ahead and send them home the same day with the catheter.

We would see them back in the office a few days later, remove the catheter, And at that point, they should start to notice almost immediately a better flow. The other symptoms typically, including urinary frequency, urgency, and getting up at night will take about two to four weeks to start to really note some improvement.

And then long term, should have improvement in the other symptoms as well along down the road.

Host: And so how long would it be after the procedure before someone is, quote unquote, back to normal?

Andres Madissoo, M.D.: Yeah, within a few weeks, they're essentially back to normal, and then we expect to see even further improvement, gradually over the next few months. Some patients will require medications initially to help with some irritative voiding symptoms, meaning still going a little more often, urge to go. We can settle that down with some medications that typically they will not require long term.

Host: A couple other things. You touched on some of the results there. Overall, though, with this procedure, is it typically going to cure the problem? If it does, will it come back or are you just looking for significant improvement?

Andres Madissoo, M.D.: Yeah, it should cure the problem. We're removing a significant amount of the enlarged prostate tissue and long term, most patients will go the majority of their life and not require any further therapy. The prostate will always continue to grow, so over time, typically over 10 years or more, they may notice some symptoms coming back, and any fix after that should be fairly simple if we had to remove some more tissue in the future.

Host: And you touched a little bit earlier on side effects, sexual side effects, etc. What should men be aware of in that regard?

Andres Madissoo, M.D.: So the aquablation, the big benefit is there's really almost no risk of difficulty with erections following the procedure. The biggest improvement compared to other therapies is really in retrograde ejaculation where the ejaculate does not come out with orgasm. So with a patient who underwent a typical transurethral resection of the prostate, the old way of treating the prostate, they could almost be assured to not have any ejaculate when they actually ejaculate or have orgasm.

Whereas with aquablation, that is preserved. Only 10 percent of patients may experience that with aquablation.

Host: And so, in summary, Doctor, how can our audience learn more about this aquablation therapy and whether it might be right for them?

Andres Madissoo, M.D.: So there is quite a bit of information online regarding the HYDROS aquablation therapy. If they're interested in hearing more or being evaluated for it, then they can certainly contact our office. They can either call the office at 315-478-4185 and set up a consultation. The other alternative is to go online at our AMP urology office, information available, and they can look that up at A M P O F N Y, and they can actually set up an appointment with me.

Host: All right. Well, folks, we trust you're now more familiar with aquablation therapy for enlarged prostate. Dr. Andres Madissoo, keep up your great work and thanks so much again.

Andres Madissoo, M.D.: I appreciate the opportunity. Thank you.

Host: Same here. And folks, for more information, aside from what the doctor just outlined, you can also visit crouse.org./news/aquablation. If you found this podcast helpful, please do share it on your social media. I'm Joey Wahler, and thanks again for being part of Crouse HealthCast, where we bring you the latest in health related news and information straight from the experts at Crouse Health.